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Demodexblepharitis (DB) has become one of the common differential diagnoses in patients presenting with red eyes in daily clinics. In this review article, we have incorporated a detailed discussion about the mite and the various mechanisms by which it causes different signs and symptoms, the risk factors, and diagnostic methods with current and emerging treatment modalities. Because of the chronic symptoms and rather a late diagnosis, DB considerably affects patients' quality of life. The clues to identify cylindrical dandruff, the diagnostic sign of Demodex, visualization of the mite correlating their presence with signs and symptoms, and instituting early and appropriate treatment are the goals of this article., (Copyright © 2024 Indian Journal of Ophthalmology.)

The aim of this study is to present a case of severe chronic blepharitis secondary to psoriasis in an eye that developed phthisis bulbi during the treatment of juvenile glaucoma. A 19-year-old male patient, who had been treated for bilateral juvenile glaucoma for many years and had phthisis bulbi in his left eye for the last 4 years, presented with the complaint of chronic eyelid inflammation in the same eye for 2 years. Examination revealed hyperemia, discharge, scaling, inflammation, and diffuse edema on the lower and upper eyelids. It was determined that she had been diagnosed with psoriasis by the dermatology clinic 3 years before her history. Psoriasis-like hyperplasia was observed in the lower eyelid biopsy. He was treated with topical periocular low potency steroid ointment (1% hydrocortisone). Clinicians should be vigilant about eyelid and eye involvement in psoriasis., Competing Interests: There are no conflicts of interest., (Copyright: © 2024 Middle East African Journal of Ophthalmology.)

Demodex infestation is the cause of more than two-thirds of all cases of blepharitis in the United States. Although symptoms may include crustiness, redness, or itching of the eyelids, diagnosis can be accomplished through a simple examination of the eyelashes. The presence of a waste product of the Demodex mite, known as collarettes, on the base of the eyelashes is a pathognomonic sign of Demodex blepharitis. Demodex infestation that results in blepharitis may cause blockage and ultimately atrophy of the meibomian glands, worsening dry eye disease. Until recently, management of Demodex blepharitis has been limited by a lack of approved therapy options. Lotilaner ophthalmic solution 0.25%, the first approved therapy for treatment of Demodex blepharitis, has not only been shown to eradicate Demodex mites in one-half to two-thirds of patients following short-term treatment but also demonstrated continued benefits through 1 year of follow-up. In addition to managing Demodex blepharitis, treatment with lotilaner ophthalmic solution 0.25% may aid in the management of dry eye disease and other forms of ocular surface disease caused by complications of Demodex infestation. As a result, it is possible that successful management of Demodex blepharitis may reduce chronic use of health care resources dedicated to managing other chronic ocular conditions. As eye care professionals recognize Demodex infestation as a key mediator of ocular surface disease, increasing diagnostic awareness and addressing this underlying cause of Demodex blepharitis may reduce the need for specialist follow-up care, decrease the need for chronic therapy, and improve patient outcomes. Through routine screening for Demodex infestation and Demodex blepharitis, eye care professionals can now address an underlying factor in ocular surface disease to improve use of health care resources in the community.

Purpose: To study the demographic, clinical, and microbiological profile of Demodex-related blepharokeratoconjunctivitis (BKC) at a tertiary eye care hospital., Methods: This retrospective observational study was conducted from January 2016 to September 2022. It included 83 patients with microbiologically proven Demodex BKC who presented to the cornea department of our tertiary care eye center. The clinical, microbiological, and demographic data of the 83 cases were analyzed., Results: Of the 83 cases, 57 (68.67%) were younger than 40 years, and 25 (30.12%) were below 20. Most patients presented with a good visual acuity of 20/40 or better (93 eyes; 84.55%). The disease was unilateral in 55 patients and bilateral in 28. Cylindrical dandruff was the predominant presentation noted in 61 eyes (54.95%), followed by corneal scarring in 47 eyes (42.34%) and corneal vascularization in 40 eyes (36.04%). On light microscopy, 87.95% of the positive samples were identified as Demodex folliculorum , 7.23% as Demodex brevis , and 6.02% remained unidentified. Tea tree oil and lid scrubs eradicated the disease in most patients clinically (75/83, 90.36%)., Conclusion: The spectrum of BKC includes both lid signs and corneal involvement. It can be a cause of recurrent BKC and detection of the mite by microscopic evaluation of the lashes can confirm the diagnosis. In most cases, the tea tree oil can effectively manage this condition. However, low doses of topical steroids are needed to control the inflammation in patients with corneal involvement., (Copyright © 2024 Copyright: © 2024 Indian Journal of Ophthalmology.)

Purpose: The management of blepharitis continues to challenge clinicians due to the poorly understood aetiology of the condition. We recently identified the family of intracellular plakin proteins as essential driving forces underlying anterior blepharitis. A large-scale protein analysis was used to study if a topical dexamethasone/tobramycin solution could be used to reverse the expression of plakin proteins., Methods: Tear film samples from treatment naïve patients with anterior blepharitis (n = 15) were collected with Schirmer filtration paper. A subgroup of the patients (n = 10) received treatment with a dexamethasone/tobramycin 1 + 3 mg/mL ophthalmic suspension (Tobradex ® ) for 3 weeks and collection of tear film samples was repeated. The samples were analysed with label-free quantification nano liquid chromatography-tandem mass spectrometry requiring quantification in at least 70% of the samples in each group. Proteins were considered differentially expressed if p < 0.05., Results: Following Tobradex ® intervention, 27 proteins were upregulated while 61 proteins were downregulated. Regulated proteins after Tobradex ® treatment were involved in intermediate filament cytoskeleton organization including downregulation of the plakin proteins envoplakin, epiplakin and periplakin. Plectin, a protein of the plakin family, remained unchanged after Tobradex ® therapy. Tobradex ® treatment resulted in the regulation of proteins involved in translation including a cluster of downregulated ribosomal proteins. Tobradex ® intervention was associated with the regulation of proteins involved in fructose metabolism and glycolytic processes including fructose-1.6-bisphosphatase 1, fructose-bisphosphate aldolases A and B, pyruvate kinase PKM and transketolase. Ig lambda chain V-I region, prominin-1, and protein Niban were upregulated after Tobradex ® treatment., Conclusions: Tobradex treatment reversed the expression of plakin proteins in anterior blepharitis. Topical solutions which inhibit the expression of plakin proteins may have the potential to restore the ocular surface integrity in anterior blepharitis and should be explored further., (© 2023 Acta Ophthalmologica Scandinavica Foundation. Published by John Wiley & Sons Ltd.)

Pthiriasis palpebrarum, a rare condition caused by Phthirus pubis , can mimic blepharitis and manifest as intense itching, inflammation and eyelid redness. We describe a case of Pthiriasis palpebrarum in a young girl with right upper eyelid discomfort. A slit lamp examination revealed eggs on her eyelashes and adult lice on the eyelids' surface. Dermatology consultation confirmed the diagnosis and successful treatment followed. Family evaluation uncovered genital Phthiriasis pubis in her parents, who received appropriate treatment. This report emphasises the importance of accurate diagnosis and management of this masquerading condition by careful slit lamp and microscopic evaluation. It also highlights the significance of comprehensive family history and examination., Competing Interests: Competing interests: None declared., (© BMJ Publishing Group Limited 2024. No commercial re-use. See rights and permissions. Published by BMJ.)

Purpose: To evaluate the prevalence of diagnosed dry eye syndrome, meibomian gland dysfunction, and blepharitis amongst the low vision population., Methods: A retrospective analysis was conducted on patients seen in the University of Colorado Low Vision Rehabilitation Service between the dates of 12/1/2017 and 12/1/2022. 74 ICD-10 codes were used to identify patients as having dry eye syndrome or not having dry eye syndrome. Data was further analyzed to determine the prevalence of blepharitis and meibomian gland dysfunction using 29 blepharitis and 9 meibomian gland dysfunction ICD-10 codes. Data were also analyzed to determine the age and sex of the patients with diagnosed dry eye syndrome., Results: The percentage of patients with a diagnosis of dry eye syndrome by an eyecare provider was 38.02 %. The prevalence of dry eye syndrome by age group was 3.57 % for 0-19 years, 14.35 % for 20-39 years, 29.07 % for 40-59 years, 43.79 % for 60-79 years, and 46.21 % for 80 and above. The prevalence of meibomian gland dysfunction and blepharitis was 11.90 % and 9.1 % respectively. Dry eye syndrome prevalence amongst males was 31.59 % and 42.47 % for females., Conclusion: This study demonstrates that dry eye syndrome in the low vision population is a significant co-morbidity occurring in over a third of patients in the University of Colorado Low Vision Rehabilitation Service. These findings are meaningful as ocular comfort should not be overlooked while managing complex visual needs., Competing Interests: Conflicts of interest The authors have no proprietary or commercial interest in any materials discussed in this article., (Copyright © 2023 Spanish General Council of Optometry. Published by Elsevier España, S.L.U. All rights reserved.)

Background: Demodex blepharitis (DB) is a common disease of the ocular surface. The characteristics of the bacterial community in eyelash roots after Demodex infestation are still unknown. Knowledge of the characteristics of the bacterial community of eyelash follicles in patients with DB can provide valuable insights for guiding the diagnosis and treatment of DB., Methods: Twenty-five patients with DB (DB group) and 21 non-DB volunteers (control group) were enrolled in the study. Eyelashes from the upper eyelid of the right eye were sampled, and 16S ribosomal DNA (rDNA) sequencing was performed to determine the V3-V4 regions of the microbial 16S rDNA gene within 1 month of infestation. The sequencing data of the two groups were analyzed and compared. The effect of the bacterium Burkholderia on the survival of Demodex mites was evaluated using Demodex obtained from 12 patients with DB other that the patients in the DB group., Results: A total of 31 phyla and 862 genera were identified in the DB and control groups. The five most abundant phyla in the two groups were Proteobacteria, Firmicutes, Actinobacteria, Bacteroidetes and Cyanobacteria. The abundance of Actinomycetes was significantly higher in the DB group than in the control group. At the genus level, the five most abundant genera in the two groups were Pseudomonas, Burkholderia-Caballeronia-Paraburkholderia, Rolstonia and Acinetobacter; Clostridium sensu stricto 1 was abundant in the control group and Corynebacterium&#95;1 was abundant in the DB group. Compared with the control group, the abundance of Burkholderia-Caballeronia-Paraburkholderia was 2.36-fold lower in the DB group. Linear discriminant analysis Effect Size (LEfSe) analysis revealed Burkholderia-Caballeronia-Paraburkholderia, SC&#95;I&#95;84&#95;unclassified, Nonmyxobacteria and Succinvibrio to be the major biomarkers in the control group and Catenibacterium and Lachnospiraceae NK4A136 group to be the major biomarkers in the DB group. To explore the performance of these optimal marker models, receiver operational characteristic curve analysis was performed, and the average area under the curve value of Burkholderia-Caballeronia-Paraburkholderia was 0.7448. Burkholderia cepacia isolated from normal human eyelashes was fermented, and the Demodex mites isolated from patient eyelashes were cultured together with its fermented supernatant. The results showed that the fermentation supernatant could significantly reduce the survival time of the Demodex mites, suggesting the potential therapeutic value of this bacterium against Demodex., Conclusions: The composition of the bacterial community in the eyelashes of DB patients differed from that in eyelashes of healthy volunteers, revealing a decrease in bacterial diversity in infested eyelashes. This decrease may be related to the occurrence and development of DB. The supernatant of Burkholderia cepacia culture medium was found to inhibit the growth of Demodex in eyelash hair follicles, providing a new insight with potential applications for the clinical treatment of Demodex infestation., (© 2024. The Author(s).)

Introduction: Chronic blepharitis is a common cause of eye irritation and dryness. They are often treated without regard to causal factors such as parasites which are rarely mentioned., Aim: To describe the role of Demodex in the pathogenesis of chronic blepharitis, to analyze the epidemiological, clinical, diagnostic and therapeutic particularities., Methods: This is a prospective, case-control study conducted in the mycology parasitology department at the Habib Bourguiba university hospital in Sfax covering 100 cases with chronic blepharitis and 87 control cases. Clinical examination and eyelash removal were performed with direct examination for qualitative and quantitative analysis, before and after treatment., Results: Demodex was significantly more found in patients than in controls (48% vs 13.8%). The quantitative analysis showed a significant difference between the two groups with 52.1% of Demodex (+++) for patients versus 8.3% for controls. Demodex blepharitis were treated with yellow oxid mercure ophthalmic ointment with a good outcome in 81,3%., Conclusion: Although it is admitted to be a saprophyte of the skin, a large number of arguments argues for the incrimination of Demodex in the etiopathogenesis of chronic blepharitis, hence the interest of eyelashes examination and a parasitic research in front of any chronic blepharitis resistant to usual treatments. In case of positive research, a specific treatment should be prescribed. Its effectiveness is another argument for the etiological diagnosis.

Nowadays, people give more importance and pay closer attention to the condition of their eyelids and lid margins. This increased recognition of eyelid hygiene is due to the growing awareness that improper eyelid cleaning might lead to various ocular surface diseases such as blepharitis and meibomian gland dysfunction. These ocular surface diseases can greatly affect people's quality of life. This article reviews the latest procedures for proper eyelid cleaning, including indications, methods, tools, detergents, and clinical applications, to maintain a healthy ocular surface and assist in the treatment of dry eye and blepharitis., (Copyright © 2023 Copyright: © 2023 Indian Journal of Ophthalmology.)

Background: Demodex blepharitis is a common chronic disease. The number of mites is associated with ocular discomfort. The accurate number derived from well-stained specimens is, hence, in favor of diagnosing, monitoring, and determining treatment responses., Methods: A cross-sectional study was conducted between April and July 2022 at the dermatology and ophthalmology clinic, Walailak University, Thailand. Adult participants with clinical suspicion of Demodex blepharitis were recruited. We examined eyelashes under light microscopy to quantify the number of Demodex mites before and after adding CSB gel. The mite counts, evaluated by an untrained investigator and an experienced investigator, were recorded and compared., Results: A total of 30 participants were included for final analysis, among which 25 (83.3%) were female. The median age was 64.0 years (IQR, 61.0-68.0). The median Demodex counts evaluated by the experienced investigator before and after adding CSB gel were 1.0 (IQR, 0.0-1.0) and 2.5 (IQR, 2.0-3.0), respectively ( p  < 0.001). Moreover, the median Demodex counts evaluated by the untrained investigator before and after adding CSB gel were 1.0 (IQR, 0.0-1.0) and 2.0 (IQR, 1.0-3.0), respectively ( p  < 0.001). The correlation coefficient between Demodex counts after the addition of CSB counted by the experienced investigator and those counted by the untrained investigator was 0.92 ( p  < 0.001). CSB gel is a promising product to identify and quantify the number of Demodex mites. The findings supported the consideration of CSB gel as one of the diagnostic stains., Competing Interests: The authors declare there are no competing interests., (©2023 Udomwech et al.)

Purpose: Daily cleansing of eyelids is very important to carry out a successful blepharitis treatment. However, there are no therapeutic guidelines for blepharitis. The aim was to compare the symptomatic relief of anterior blepharitis using Blephamed eye gel, a cosmetic product, versus standard treatment., Methods: The study was a prospective, interventional open label clinical trial at a university-based hospital. The test population was subjects aged 18-65 years who presented with mild to moderate anterior blepharitis. Eyelid hygiene was applied twice a day. At each visit, a detailed assessment of symptomatology was carried out. A two-way repeated measure mixed model ANOVA was used to compare two groups by time., Results: In total, 61 patients with mean age of 60.08 ± 16.69 years were enrolled in the study including 30 patients in standard group and 31 patients in Blephamed group. Two groups did not differ in terms of age (P = 0.31) and eye laterality (P = 0.50). The baseline scores of erythema, edema, debris, and symptoms as well as total score were similar between two groups (all P values >0.50). Two groups became different for all these parameters at day 45 (all P values <0.001). Significant interaction was detected between time and intervention groups for all severity parameters of blepharitis as well as total score (all P values <0.001)., Conclusion: Eyelid hygiene with Blephamed more significantly decreased symptoms of anterior blepharitis compared to standard treatment., Competing Interests: None

Rosacea is a chronic, inflammatory facial dermatosis commonly found in fair skin tone population. Recent studies have shown the increasing prevalence in the dark skin tone population as well. Ocular involvement is very common and can occur without cutaneous features. Common ocular features are chronic blepharoconjunctivitis with eyelid margin inflammation and meibomian gland dysfunction. Corneal complications include corneal vascularization, ulceration, scarring, and rarely, perforation. Diagnosis is largely based on clinical signs, although it is often delayed in the absence of cutaneous changes, particularly in children. The management ranges from local therapy to systemic treatment, depending on the severity of the disease. There is a positive association between demodicosis and rosacea; however, causality is always argued. In this review, we describe the epidemiology, clinical features, and treatment of rosacea and ocular rosacea., Competing Interests: None

Inflammatory eyelid symptoms are common in primary care and there have been several reports on Demodex blepharitis. In the present study, we evaluate the 9 patients with Demodex blepharitis, who showed inflammation of the eyelids, dry eye, and cylindrical dandruff at the base of the eyelashes. The causative species from all patients was Demodex folliculorum of either the adult or nymph stage. Two patients had recurrent chalazion and 3 patients had keratitis. Weekly lid scrubs with 50% tee tree oil were performed for 6 weeks. After treatment, the symptoms of blepharitis and keratitis had improved in all patients. This case report provides clinical reference source for the proper treatment of ocular demodicosis.

Purpose: To study the clinical presentations and outcomes of phthiriasis palpebrarum (PP) managed with combined treatment modality comprising of 20% fluorescein dye, mechanical removal of the ectoparasites, and topical application of antibiotic eye ointment with paraffin base., Methods: This is a prospective interventional noncomparative hospital-based series of 13 patients of PP. All the patients underwent local application of 20% fluorescein dye over the eyelashes and eyebrows of both the eyes followed by the mechanical removal of all the ectoparasites and trimming of the eyelashes from the base followed by application of ophthalmic ointment., Results: Mean age of the patients was 28 ± 22 years (range 3-60 Years). Out of the total of 13 patients, 11 patients (85%) were having bilateral involvement. The mean duration of symptoms in 11 patients (rest 2 were accidental findings) was 4 ± 3 weeks (range 1-10 weeks). Three patients (23%) had a history of sexual contact with possible parasite-infested partners. Four patients (31%) had additional parasites in the pubic area or torso. All the patients were completely parasite free at the end of 1 month. There was no infestation of the treating medical personnel from the patient. The average follow-up was 8 ± 5 months (range 3-21 months)., Conclusion: Itching and irritation of the eyes were the most common presentations of PP. Combined treatment modality comprising of 20% fluorescein dye, mechanical removal of ectoparasites, and topical application of antibiotic eye ointment with paraffin base is effective in the management of PP., Competing Interests: None

Purpose: To investigate the efficacy of lid wipes (LWs) containing terpinen-4-ol and sodium hyaluronate (Hy-ter ® ) for the treatment of seborrheic blepharitis compared to baby shampoo (BS)., Methods: This randomized, double-blind, active control, parallel group, multicentre clinical trial included 48 eyes of 48 patients with seborrheic blepharitis who were randomly divided into two treatment arms (1:1, n = 24) using block randomization. LWs or BS were prescribed twice a day for 8 weeks followed by a discontinuation period of 4 weeks. Change in Blepharitis Symptom measure (BLISS), Schirmer's test, tear breakup time (TBUT), noninvasive TBUT (NI-TBUT), ocular surface disease index (OSDI) score, corneal and conjunctival staining, meibography, and Demodex count at different visits (Baseline, 4th, 8th, and 12th week) were the main outcome measures., Results: The baseline values of both groups were similar (p > 0.05). Despite high clinical efficacy in both treatment arms, patients using LWs showed a lower BLISS score at the 8th and 12th-week visit (1.9 ± 2.2 versus 7.2 ± 6.6, p = 0.003; 4.0 ± 1.3 versus 5.8 ± 6.3, p = 0.026). NI-TBUT showed a significant increase starting from the 4th week for patients using LWs and 8th week for patients using BS. Both treatment modalities caused a reduction in the Demodex count after 4 weeks of treatment (p < 0.001). The treatment withdrawal did not cause any recurrence in both treatment arms., Conclusion: BS or LWs containing Hy-ter ® can be used with good efficacy for the treatment of seborrheic blepharitis. However, LWs may provide a better symptomatic relief compared to BS after 8 weeks of treatment., (© 2021. The Author(s), under exclusive licence to The Royal College of Ophthalmologists.)

Purpose: To evaluate morphological alterations of meibomian glands (MGs) in the dry anophthalmic socket syndrome (DASS)., Methods: Fifteen unilateral anophthalmic patients wearing cryolite glass prosthetic eyes were enrolled. All patients with clinical blepharitis or other significant eyelid abnormalities were excluded. In vivo laser scanning confocal microscopy (LSCM) of the MGs in the lower eyelids both on the anophthalmic side and the healthy fellow eye was performed to quantify acinar unit density, acinar unit diameter, acinar unit area, meibum secretion reflectivity, the inhomogeneous appearance of the glandular interstice, and inhomogeneous appearance of the acinar walls., Results: The lower eyelids of the anophthalmic sockets revealed a significant reduction of the acinar unit density (p = 0.003) as well as a significantly more inhomogeneous appearance of the periglandular interstices (p = 0.018) and the acinar unit walls (p = 0.015) than the healthy fellow eyelid. However, there were no significant differences regarding the acinar unit diameter, acinar unit area, and meibum secretion reflectivity of the MGs on the anophthalmic side compared to the healthy fellow eyelid (p ≥ 0.05, respectively)., Conclusions: The eyelids of anophthalmic sockets without clinical blepharitis demonstrate a reduced density of MG acinar units and a more inhomogeneous appearance of the periglandular interstices and the acinar unit walls. This can cause meibomian gland dysfunction contributing to DASS and suggests early treatment of these symptomatic patients, even in the clinical absence of any blepharitis signs., (© 2021. The Author(s).)

Introduction: Demodex mite is an external parasite which is implicated in various ocular conditions like anterior blepharitis, posterior blepharitis, meibomian gland dysfunction, chalazia and others. Although demodex has been shown to be a causative agent of chalazia, occurrence of a solitary inflammatory nodule due to demodex infestation has not been reported in literature., Case: Our case describes the occurrence of an upper eyelid mass in a 62-year-old female which was found to have an associated demodex infestation., Conclusion: This is the first report of demodex infestation presenting as a nodular eyelid mass. This parasite needs to be considered in the differential diagnosis of eyelid masses as this condition requires specific management., (© NEPjOPH.)

Background: Phthirus pubis is an obligate parasite of human beings. Demodex spp. is a much more common parasite of human beings. However, P. pubis infestation accompanied by Demodex mite infestation in eye has not been reported., Case Presentation: We report the first case of Phthirus pubis and Demodex co-infestation on a 48-years-old woman. She presented to the hospital with itching and burning at her right eye for 2 weeks. Slit lamp examination revealed multiple nits and adults of P. pubis anchored to both upper and lower eyelashes. Eyelashes were trimmed, moxifloxacin eye ointment and fluorometholone eye drops were initiated daily. However, itching didn't improve after 2 weeks of treatment. Light microscopy examination of eyelashes revealed infestation with Demodex. The patient was treated with lid scrubs with 25% tea tree oil daily for 4 weeks and was completely cured., Conclusion: Our report shows the importance of an early and comprehensive diagnosis, because both phthiriasis palpebrarum and demodicosis can be confused with blepharitis.

Phthiriasis palpebrarum is a rare eyelid infestation caused by Phthirus pubis (pubic lice) that is often confused with other causes of blepharoconjunctivitis. In this study, we report the case of a 49-year-old male patient with phthiriasis palpebrarum who presented with itching and eye irritation in the left eye and had undergone treatment for conjunctivitis in the past month. Biomicroscopic examination revealed a dense population of motile and translucent lice and eggs, more intensely on the upper lid. For treatment, the lice were first cleaned mechanically, eyelashes were cut from the bottom, and eggs and lice were removed from the eye, after which petrolatum jelly (vsaseline) was applied to the lids for 10 days. In the control examination, no lice and eggs were observed.

Purpose: To report clinical characteristics of Demodex blepharokeratoconjunctivitis affecting young patients., Methods: This is a retrospective review of 14 patients with the history of chronic red eyes with corneal involvement. All patients were diagnosed with ocular demodicosis based on the results of eyelash sampling. All patients were treated with 50% tea tree oil lid scrubs and two doses of oral ivermectin (200 mcg/kg)., Results: The median age of patients at diagnosis was 27 years (range: 11-39 years). The duration of symptoms ranged from 2 months to 20 years. Rosacea was present in only three patients. Four patients had best corrected visual acuity less than 20/60. Allergic conjunctivitis (n = 7) and viral keratitis (n = 5) were the most common misdiagnosis previously made. Cylindrical dandruff was present in only six patients and eyelashes were clean in rest of them. Inferior vascularization was present in eight eyes, superior in seven eyes, and corneal scars were present in 12 eyes. Four patients had steroid-related complications. All patients, except one responded to tea tree oil treatment and 13 patients were off steroids after 3 weeks of starting the treatment., Conclusion: Demodex infestation of eyelids can lead to chronic blepharokeratoconjunctivitis in healthy pediatric and young adult patients who otherwise have good hygiene, which can often be overlooked or misdiagnosed. Viral keratitis and allergic conjunctivitis are common misdiagnoses and demodicosis can be confirmed by simple epilation. Early diagnosis and treatment can prevent long-term steroid use and its related complications., Competing Interests: None

Purpose: To evaluate non-contact infrared meibography and anterior segment optical coherence tomography (AS-OCT) to detect meibomian gland (MG) and corneal changes in children with blepharokeratoconjunctivitis (BKC)., Methods: We acquired infrared meibography images of upper and lower lids and AS-OCT corneal scans. One masked observer graded meiboscore, full/partial MG dropout, and measured total corneal volume and differential corneal volume per quadrant and central corneal thickness (CCT)., Results: We enrolled 63 children, 31 with BKC and 32 without ocular surface inflammation; median (interquartile range) age BKC 10.6 (7.2-13.9) years, healthy volunteers (HV) 11.4 (9.5-13.8) years. Likert scale scores for meibography and OCT indicate no to low discomfort. Meiboscores for upper and lower lids as well as the total meiboscore were significantly higher in children with BKC than in HV. Subscores for full and partial MG dropout were also significantly higher in children with BKC than in healthy volunteers. There was no statistically significant difference between upper and lower lid for meiboscore nor full/partial MG dropout scores. The corneal volume in the superior quadrant was significantly higher in children with BKC than in HV, whereas the corneal volume in the nasal and inferior quadrants was significantly lower., Conclusions: Non-contact imaging technologies objectively demonstrate damage to meibomian glands and changes in corneal volume secondary to BKC. The tests are well tolerated by children with mild/moderate ocular surface inflammation and can detect changes without the requirement for routine eversion of the upper lid. These parameters may be useful both for clinical follow-up and clinical trials., (© 2019 Acta Ophthalmologica Scandinavica Foundation. Published by John Wiley & Sons Ltd.)

Competing Interests: Competing interests: None declared.

Phthiriasis palpebrarum (PP) is the infestation of eyelids caused by the ectoparasite Phthirus pubis, frequently misdiagnosed as allergic conjunctivitis, blepharitis or dermatitis. There is no standard treatment of choice although various treatment modalities have been described. A 6-year-old male child with PP was successfully treated with local application of 20% fluorescein solution over the eyelashes and eyebrows of both the eyes, followed by the mechanical removal of all parasites and trimming of the eyelashes from the base and application of ophthalmic ointment., Competing Interests: None

A six-year-old male patient was admitted to our hospital due to itching and scalding crusts that persisted 10-15 days in both eyes. Upon biomicroscopic examination, 5-6 semi-translucent, yellowish brown living lice attached to the upper eyelashes and a large number of eggs were observed. Following application of pilocarpine hydrochloride (Pilomann 2%, Bausch-Lomb) and topical proparacaine hydrochloride (Alcaine 0.5%, Alcon), the paralyzed parasites and eggs were manually removed by pulling with forceps. The lice were identified as adult forms of pubic louse, Pthirus pubis, and its eggs. The patient was treated with pilocarpine hydrochloride, which was applied thrice a day combined with pure vaseline. One week later, no lice or eggs were seen on the eyelashes.

Purpose: The objective of the study is to compare the frequency of Demodex on the eyelash follicle of patients with rosacea and referents without rosacea or ophthalmological disorders., Methods: This is a comparative, open, observational, and cross-sectional study that included 41 patients diagnosed with rosacea and 41 referents without rosacea diagnosis or ophthalmic alterations. The individuals underwent a slit-lamp examination in which two eyelashes per eyelid were removed with fine forceps. The presence of Demodex was sought by direct visualization under a light microscope. The results were expressed as "positive" when at least one mite on one lash was found and "negative" when no mite was identified. Chi-square test was used to compare the presence of mites in both groups., Results: Eighty-two study individuals (45 females and 37 males) were included, of which 41 patients were diagnosed with rosacea and 41 were without rosacea or ophthalmic alterations. The average mean age was 37 years with a minimum of 19 and a maximum of 87 years. Of the 41 patients with rosacea, 31 had erythematotelangiectatic rosacea and 10 had papulopustular rosacea. There were no patients with phymatous or ocular rosacea. The presence of Demodex was found in 32 patients: 24 patients with rosacea diagnosis (16 of the erythematotelangiectatic subtype and 8 of papulopustular subtype) and 8 patients without rosacea or ophthalmic alterations (P ≤ 0.001)., Conclusion: Rosacea was found to be a statistically significant risk factor for Demodex infestation in eyelashes, irrespective of age and sex, with a higher prevalence in papulopustular variety.

BACKGROUND Demodex may cause chronic and refractory blepharitis with associated ocular surface problems, and its diagnosis and treatment can be quite challenging. In this study, our aim was to assess the efficacy of tea tree oil in Demodex treatment on caucasian patients in an industrialized region of Turkey, and to develop a systematic scoring system for extremely accurate diagnosis in the absence of advanced facilities. MATERIAL AND METHODS Charts of 412 patients with blepharitis were reviewed. A group of 39 out of 412 cases were identified as chronic and treatment-refractory, and therefore were enrolled in this study. Eyelashes from each of the lower and upper eyelids of both eyes were evaluated at ×40 and ×100 magnification using light microscopy. Treatment was started with 4% tea tree oil eyelid gel and 10% eyelash shampoo. Symptoms and findings were scored according to the most common complaints. RESULTS The mean age of the patients was 54.1±15.4 years. Seventeen (43.5%) patients were male and 22 (56.5%) patients were female. In 30 out of the 39 patients (76.9%) D. folliculorum was detected. Symptoms disappeared in 25 patients. The mean score of patients who were Demodex-negative was 2.7±1.0, and the mean score of patients who were Demodex-positive was 3.8±1.6 (p=0.047). Ninety-four percent of those with a score of 4 and over were found to be Demodex-positive (p=0.025). CONCLUSIONS Treatment with tea tree oil can be successful. If there is no facility to identify Demodex under light microscopy, we recommend starting treatment for patients who have scores of 4 and over using the scoring chart developed in this study.

Purpose: To evaluate the meibomian gland function, morphology and the related medical history of patients with blepharokeratoconjunctivitis (BKC) in comparison with healthy population and meibomian gland dysfunction (MGD)-induced evaporative dry eye (EDE) patients., Methods: Twenty-two eyes of 22 Asian adult patients with BKC were enrolled as the BKC group. Healthy volunteers and MGD-induced EDE patients were recruited in a 1:1 ratio and were matched in age, and the gender compositions of the three groups were also comparable. Examinations included meibum quality, meibomian gland expressibility, meibomian gland dropout and relevant ocular surface tests. Related medical history was recorded., Results: The BKC group had higher incidences of chalazion (OR 4.59, 95% CI 1.29-16.33) and eyelid surgery (OR 4.91, 95% CI 1.33-18.21) than the control group (chalazion, p = 0.007; eyelid surgery, p < 0.001) and EDE group (chalazion, p = 0.031; eyelid surgery, p = 0.005) had. All clinical indexes were worse in the BKC group than in the control group (all p < 0.05). The EDE group had better meibum quality (p = 0.049) and less meibomian gland dropouts (all p < 0.05) than the BKC group. The dropouts of the BKC group were the highest among the three groups, and the distribution over the tarsal plate was even in the BKC group (all p > 0.05)., Conclusions: Patients with BKC had worse meibomian gland function, poorer morphology and a higher rate of medical histories related to the meibomian gland than the healthy population. The BKC clinical features of meibum quality and meibomian gland dropout were different from other MGD diseases., (© 2016 Acta Ophthalmologica Scandinavica Foundation. Published by John Wiley & Sons Ltd.)

Background: Blepharitis is a very common condition encountered in ophthalmology outpatient care department. Dermatological diseases like seborrheic keratopathy and rosacea have been frequently discussed as being associated with blepharitis. However Discoid lupus erythematosis [DLE], an autoimmune condition has only rarely been reported to involve the eyelids mimicking blepharitis. DLE affecting the eyelids can produce significant morbidity with lid deformities, trichiasis and symblepharon if left untreated., Objective: To report three consecutive cases of DLE with eyelid lesions mimicking blepharitis. They presented to the department of ophthalmology at our institute from April 2014 to March 2016. The first case presented with involvement of lower eyelid in one eye. She was having multiple skin lesions which on biopsy confirmed the diagnosis of DLE. The second case was a diagnosed case of DLE who received treatment 4 years back and came with relapse of the disease affecting the eyelid. The third case was a recently biopsy confirmed case of DLE with multiple skin lesions along with bilateral eyelid involvement. Two of them had madarosis and one case had destruction of the outer lid margin at presentation. All three cases responded well to treatment with Hydrxychloroquin., Conclusion: The discoid lesions of DLE affecting the eyelids can mimic the appearance of chronic blepharitis. Ophthalmologists should be aware that DLE is a possibility while dealing with an atypical case of chronic blepharitis. Early diagnosis and treatment can prevent deformities of eyelid., (© NEPjOPH.)

Demodecidosis is an ectoparasitosis of pilosebaceous unit caused by demodex mites. The disease may be a primary skin disease or a secondary disease to inflammatory dermatoses such as folliculitis and rosacea. Demodex spp. blepharitis is an infectious ocular disease that is common but always neglected. These mites contain lipase enzymes that help carry bacteria on the surface. The infestation of Demodex spp. has increasingly become a public health concern. A 29-year-old male patient was admitted to our dermatology clinic with a complaint of papules and pustules on his face, which started 4 years ago. A standardized skin biopsy specimen was evaluated in our microbiology laboratory, and we detected Demodex folliculorum mites on his face (3+). There was pruritus of his eyes. A total of four eyelashes were epilated and were then examined under a light microscope for the presence of Demodex infestation. In this study, we discussed the association between acne rocacea, blepharitis, and demodex mites.

Aspergillus species produces a wide spectrum of fungal diseases like endophthalmitis and fungal keratitis ophthalmologically, but there has been no report about blepharitis caused by Aspergilus flavus to date. Herein, we report a 61-year-old ethnic Han Taiwanese male who had suffered from pain with burning and foreign body sensation after an insect bite on his left eye. Specimens from bilateral eyelids suggested infection of A. flavus, whereas corneal scraping showed the presence of Gram-negative bacteria. He was admitted for treatment of infectious keratitis with topical antibiotic and antifungal eye drops. Two weeks after discharge, recurrent blepharitis and keratitis of A. flavus was diagnosed microbiologically. Another treatment course of antifungal agent was resumed in the following 6 months, without further significant symptoms in the following 2 years. Collectively, it is possible for A. flavus to induce concurrent keratitis and blepharitis, and combined treatment of keratitis as well as blepharitis is advocated for as long as 6 months to ensure no recurrence., (© The American Society of Tropical Medicine and Hygiene.)

Unlabelled: Meibomian gland dysfunction (MGD) is a common cause of dry eye disease. Demodex mites can cause MGD with symptoms like itching, dryness and general ocular discomfort. It is important to consider infestation with Demodex mites in individuals who are non responsive to traditional MGD treatment but also equally important when cylindrical dandruff is seen at the base of the eye lashes.. We report two individuals who had not responded to ocular and systemic treatment for MGD and were then diagnosed with Demodex mites. Treatment with BlephEx and Tea tree oil was successful. This is the first report on Demodex folliculorum in Iceland where a genetic analysis was done., Key Words: Demodex, blepharitis, debris, tea tree oil, dry eye. Correspondence: Sigurlaug Guðrún Gunnarsdóttir sigurlaug@sjonlag.is.

Purpose: To evaluate the presence of fungi in patients with chronic anterior blepharitis with periodic acid-Schiff (PAS) staining of the eyelashes in addition to the conventional methods of fungal cultures and direct microscopy., Methods: Nineteen patients with chronic anterior blepharitis of seborrheic or mixed seborrheic/staphylococcal type and 11 healthy age- and sex-matched controls were included in this prospective, nonrandomized, cross-sectional study. Blepharitis was diagnosed based on clinical evidence of greasy scales between the cilia, lid margin erythema, conjunctival hyperemia, telangiectasia, thickening, or irregularity of the eyelid margins by slit-lamp biomicroscopy. Eyelash samples were obtained by epilation with a sterile forceps and evaluated with PAS staining, fungal cultures, and direct microscopy., Results: We demonstrated fungal elements with PAS staining in 79% of the blepharitis group (hyphae and/or spores) and 18% of the control group. The difference was statistically significant (P=0.002). Four patients in the blepharitis group (21%) had positive cultures for fungi. The isolated fungi were Penicillium species (2 cases), Candida species (1 case), and Trichophyton verrucosum (1 case). Direct microscopic examination revealed Demodex mites in 42.1% of the blepharitis group. No culture growth or Demodex mites were observed in the control group., Conclusions: We have shown fungi with PAS staining in the majority of patients with chronic anterior blepharitis. Further controlled studies are necessary to clarify the role of fungi in the etiopathogenesis of blepharitis.

Purpose: To determine the incidence and density of Demodex species on the eyelashes of subjects with normal eyelids, anterior blepharitis (AB), meibomian-gland dysfunction (MGD), and mixed blepharitis (MB)., Materials and Methods: One hundred and fifty consecutive patients diagnosed with AB, MGD, and MB were recruited. An additional 50 individuals were recruited who were free of lid and margin disease to serve as a control group. All patients underwent a standard eye examination. Data on ocular symptomatology were gathered. Digital photography was performed of the lid margins. Lash sampling was performed by epilating the lashes and the lashes were checked for Demodex based on morphology using light microscopy. The total number of mites were tabulated for each eye. Comparison between the affected eyes and the control eyes was performed. Data were analyzed using the Chi-square test., Results: A total of 200 patients were included. Twenty percenth had AB, 40% had MGD, and 40% had MB. The incidence of Demodex infestation was 90% in cases of AB, 60% in MGD cases, and 90% in MB cases. The incidence of Demodex in control subjects was 18%., Conclusions: The incidence and density of Demodex infestation was highest in patients with AB and MB. Lid irritation and presence of cylindrical dandruff were indicative of a high-density infestation. These signs should alert the clinician to treat concomitant Demodex infestation.

Red eye and relapsing conjunctivitis-blepharitis are among the most common ocular disease in elderly patients. In these cases the search for causes is difficult and frustrating. We report the case of a 79-year-old woman with a long history of red eye and relapsing conjunctivitis-blepharitis caused by ocular rosacea. In this patient the proper diagnosis was performed after 10 years of ocular disease, and repeated evaluations by general practitioners and clinical specialists, only after the appearance of facial signs of erythematotelangiectatic rosacea. Adequate therapy with oral doxycycline led to the improvement of the clinical picture that previously had shown a poor response to several topical treatments. The possibility of ocular rosacea should be considered in evaluating an elderly patient with persistent red eye and relapsing conjunctivitis-blepharitis. Making the proper diagnosis is crucial because ocular rosacea does not respond as expected to topical therapy and may lead to severe corneal involvement., (2014 BMJ Publishing Group Ltd.)

Objective: The diagnosis of Sjögren's syndrome (SS) in routine practice is largely a clinical one and requires a high index of suspicion by the treating physician. This great dependence on clinical judgment frequently leads to delayed diagnosis or misdiagnosis. Tear protein profiles have been proposed as simple and reliable biomarkers for the diagnosis of SS. Given that cathepsin S activity is increased in the lacrimal glands and tears of NOD mice (a murine model of SS), the aim of this study was to explore the clinical utility of using tear cathepsin S (CTSS) activity as a biomarker for SS., Methods: A method to measure CTSS activity in tears eluted from Schirmer's test strips was developed and validated. Schirmer's tests were performed and CTSS activity measurements were obtained in 278 female subjects, including 73 with SS, 79 with rheumatoid arthritis, 40 with systemic lupus erythematosus, 10 with blepharitis, 31 with nonspecific dry eye disease, and 12 with other autoimmune diseases, as well as 33 healthy control subjects., Results: The median tear CTSS activity in patients with SS was 4.1-fold higher than that in patients with other autoimmune diseases, 2.1-fold higher than that in patients with nonspecific dry eye disease, and 41.1-fold higher than that in healthy control subjects. Tear CTSS levels were equally elevated in patients with primary SS and those with secondary SS, independent of the Schirmer's test strip values or the levels of circulating anti-SSA or anti-SSB antibodies., Conclusion: Markedly high levels of tear CTSS activity are suggestive of SS. CTSS activity in tears can be measured in a simple, quick, economical, and noninvasive manner and may serve as a novel biomarker for autoimmune dacryoadenitis during the diagnostic evaluation for SS., (Copyright © 2014 by the American College of Rheumatology.)

A case of leishmaniasis with predominantly ocular signs in a cat living in Switzerland and it's treatment is reported. The cat was imported from Spain 4 years earlier and was initially presented with chronic uveitis. Laboratory test results were negative for feline immunodeficiency virus (FIV), feline infectious peritonitis (FIP), feline leukaemia virus (FeLV) and Toxoplasma gondii, as well as for Bartonella haenselae and Leishmania spp. Twenty-one months later the cat was presented again because of development of keratitis and granulomatous blepharitis. Blood cell count revealed severe Pancytopenia; Cytology of fine needle aspirates of granulomatous lesions on both upper eyelids and of a corneal smear revealed intracytoplasmatic microorganisms. A preliminary diagnosis of leishmaniasis was supported by positive polymerase chain reaction from bone marrow and eyelid samples for Leishmania infantum DNA and by a high serum antibody titer for Leishmania spp. Treatment with Allopurinol (10 mg/kg, BID) orally led to rapid improvement of ocular signs, general condition and blood cell count with complete remission of lid and corneal lesions within 2 months of treatment.

Background: The efficacy of topical ophthalmic corticosteroids depends upon small modifications in preparations, such as drug concentration.The aim of this study was to confirm that hydrocortisone acetate (HC-ac) ophthalmic ointments of 2.5% and 1% are more effective than a 0.5% eye ointment., Methods: In this randomized, double-blind, placebo-controlled, parallel-group clinical study, the change of signs and symptoms of acute inflammation of the ocular surface and adnexa was evaluated in 411 subjects., Results: Median time to clinically relevant response as estimated by 50% reduction in clinical signs and symptoms (CSS) total score over the entire trial was similar for subjects treated with HC-ac 2.5% (73.5 h) and for subjects treated with HC-ac 1.0% (67.7 h) and was considerably and significantly longer for subjects treated with HC-ac 0.5% (111.8 h) [p < 0.001 for both dosages]. All trial medications were safe and well tolerated., Conclusion: Hydrocortisone acetate 2.5% and Hydrocortisone acetate 1% eye ointments are efficacious and safe treatments for acute inflammations of the ocular surface or adnexa, and showed significantly better efficacy than a control group treated with Hydrocortisone acetate 0.5% therapy., Trial Registration: Current Controlled Trials ISRCTN15464650.

We present a case of blepharitis with symptoms lasting two years in duration and refractory to a host of prior medical treatments, including antibiotics, corticosteroids, cyclosporine, and baby shampoo. We recognized the clinical presentation as pathogomonic for demodicosis caused by the parasitic mite, demodex folliculorum, confirmed with light microscopy, and treated appropriately with tea tree oil and hygiene measures--achieving full resolution of symptoms. We highlight the presentation, treatment, and underscore demodicosis as an important, under recognized cause of blepharitis.

A 70-year-old woman came to ophthalmology outpatient department with complaints of repeated episodes of itching, redness and watering in both eyes of 3 months duration. She was treated with antibiotics elsewhere but had no improvement. Slit lamp examination showed lice and nits anchored to the eyelashes. Light microscopic examination of the matted eye lashes and crusts further helped in identification of the ectoparasites as Phthirus pubis (Pubic louse or Crab louse) with typical morphology.

Background: Even though air pollutants exposure is associated with changes in the ocular surface and tear film, its relationship to the clinical course of blepharitis, a common eyelid disease, had not yet been investigated. Our objective was to investigate the correlation between air pollution and acute manifestations of blepharitis., Method: We recorded all cases of changes in the eyelids and ocular surface, and rated clinical findings on a scale from zero (normal) to two (severe alterations). Daily values of carbon monoxide, particulate matter smaller than 10 μm in diameter and nitrogen dioxide concentrations and meteorological variables (temperature and relative humidity) in the vicinity of the medical service were obtained. Specific linear regression models for each outcome were constructed including pollutants as independent variables (single pollutant models). Temperature and humidity were included as confounding variables., Results: increases of 28.8 μg/m(3) in the concentration of particulate matter and 1.1 ppm in the concentration of CO were associated with increases in cases of blepharitis on the day of exposure (5 cases, 95% CI: 1-10 and 6 cases, 95% CI: 1-12, respectively)., Conclusion: Exposure to usual air pollutants concentrations present in large cities affects, in a consistent manner, the eyes of residents contributing to the increasing incidence of diseases of the eyelid margin., (Copyright © 2011 Elsevier Inc. All rights reserved.)

Purpose: To evaluate morphologic changes in meibomian glands (MGs) and the status of periglandular inflammation in patients with primary and secondary Sjögren's Syndrome (SS) using in vivo confocal laser microscopy (LSCM)., Methods: Twenty patients with primary SS (SSI), 25 with secondary SS (SSII), 20 with MG dysfunction (MGD), and 25 age- and gender-matched control subjects were enrolled consecutively. Each participant completed an Ocular Surface Disease Index questionnaire and underwent a full eye examination, including tear film break-up time (BUT), fluorescein and lissamine green staining, Schirmer test, and an LSCM examination of the MGs, the last to determine acinar unit density and diameter, glandular orifice diameters, meibum secretion reflectivity, inhomogeneous appearance of glandular interstice, and acinar wall., Results: All parameters indicated statistically significant differences among groups (P < 0.001, Kruskal-Wallis test). LSCM demonstrated no differences between SSI and SSII (Mann-Whitney U test). Compared with control subjects, SS subjects' MGs showed more periglandular inflammation and higher secretion reflectivity (P < 0.001, Mann-Whitney U test). Compared with MGD patients, SS patients' MGs had higher acinar density, smaller diameters, greater density of periglandular inflammatory cells, and lower secretion reflectivity (P < 0.001, Mann-Whitney U test). In SS patients, the two measured confocal signs of inflammation were significantly interrelated and correlated with corneal fluorescein staining (P ≤ 0.01, Spearman correlation coefficient). Acinar density and diameters were strongly correlated among themselves (P < 0.001) and with BUT (P < 0.05)., Conclusions: LSCM is capable of effectively revealing morphologic and inflammatory changes in MGs and showed discernible patterns of MG abnormalities in SS and MGD not easily distinguishable by the usual clinical exams.

Purpose: To investigate the applicability of in vivo laser scanning confocal microscopy in the diagnosis and follow-up of ocular demodicosis infestation in a prospective controlled study., Methods: Fifteen right eyes of 15 patients with blepharitis associated with cylindrical dandruff (10 males, 5 females; mean age: 62.9 ± 9 years) and eight right eyes of eight age- and sex-matched control subjects underwent HRTII/RCM, evaluation of ocular symptom scores, tear function tests including vital stainings, Schirmer test, and tear clearance test, and evaluation of mite numbers in the eyelids., Results: In vivo confocal microscopy effectively disclosed the mites in the terminal bulbs of the eyelashes, which were not observed after treatment. Eyelids with demodicosis infestation showed marked inflammatory infiltrates around the meibomian glands and conjunctiva, which cleared with tea tree oil treatment., Conclusions: Laser scanning confocal microscopy seems to be an efficient noninvasive tool in the diagnosis and follow-up of ocular demodicosis infestation.

Nine lactating dairy cows were evaluated because of eye lesions. Examination revealed mild to severe ulceration of the lower and/or upper eyelids, mild to severe swelling surrounding affected eyes, and profuse lacrimation. Lesions typically affected 1 eye, and involved the eyelid skin and conjunctiva. Oxytetracycline treatment led to cure within 2 wk.